Acute Osteomyelitis Research Articles

1160. Predictive Factors to Guide Empiric Antimicrobial Therapy of Acute Hematogenous Osteomyelitis in Children

Abstract Background Acute hematogenous osteomyelitis (AHO) is a serious infection in children. ESPID guidelines recommend empiric therapy with antistaphylococcal β-lactams in regions with a low methicillin-resistant S. aureus (MRSA) prevalence. In areas with a moderate-high prevalence of MRSA, selection of empiric therapy can be more challenging. We sought to examine factors present at the time of admission which may predict etiology and guide treatment in pediatric AHO in a region with endemic MRSA. Methods We reviewed admissions with ICD9/10 codes for AHO from 2011-2020 in otherwise healthy children. Patients with chronic infection, open or penetrating trauma, orthopedic hardware in situ, or disease secondary to a contiguous focus were excluded. Medical records were reviewed for clinical and laboratory parameters present on the day of admission. Results 586 cases were included. An etiology was identified in 76.8% of cases and S. aureus was most commonly identified (66.2%, 19% MRSA, Figure 1). Infection due to Kingella kingae (0.7%) occurred in younger children (p=0.01). Significant differences in presenting features were noted across pathogens, although S. aureus dominated in all sub-groups (Figure 2). Among children with respiratory symptoms at presentation, Group A Streptococcus (GAS, 10.7%), and S. pneumoniae (2.6%, p=0.01) were identified twice as frequently. Among children with reptiles exposure, Salmonella was identified in 10.8% (p=0.04). Multifocal infections and those requiring ICU admission were due to S. aureus in 88% and 97% of cases, respectively; these cases were disproportionately MRSA (36.4%, p=0.01 and 54%, p< 0.001). Both ESR and CRP were higher among MRSA compared to any other pathogen (Figure 3, p< 0.01). A CRP at presentation > 7 mg/dl had a 79.6% sensitivity for MRSA infection with a negative predictive value of 91.5%. Among those with either an ESR > 50 mm/hr or a CRP > 7 mg/dl, an organism was identified in 83.2% Depiction of the relative frequency of major pathogens among a cohort of 586 cases of acute hematogenous osteomyelitis in children Depiction of the relative frequency of different organisms in children with AHO with various history, exam and laboratory findings Scatterplot depicting ESR and CRP levels across major hematogenous osteomyelitis pathogens Conclusion Subtle differences in symptoms, history and laboratory parameters can provide clues to etiology in pediatric AHO. A CRP > 7 mg/dl at time of presentation is suggestive of MRSA AHO, and this should be considered when planning empiric therapy. Likewise, the absence of extreme elevation of CRP may serve an antibiotic stewardship role in MRSA endemic regions. Disclosures Sheldon L. Kaplan, MD, Pfizer (Research Grant or Support) Jonathon C. McNeil, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Allergan (Grant/Research Support)Nabriva (Grant/Research Support, Other Financial or Material Support, Site PI for a multicenter trial)

Osteomyelitis in a General Pediatric Ward

INTRODUCTION: Pediatric acute osteomyelitis (AO) is a serious condition and a challenging diagnosis. It mainly affects previously healthy individuals and Staphylococcus aureus is the leading causative agent. The objective of this study was to characterize all pediatric AO cases admitted to a second-level hospital during a six-year period.METHODS: Retrospective single-center study, including all children under 18 years-old with a primary diagnosis of AO. Descriptive statistics analysis was performed.RESULTS: Ten cases were identified, 60% males. The median age was 6.7 years. Previous trauma was referred by five. Affected locations were foot (n=3), tibia (n=3), femur (n=2), sacrum (n=1) and hand (n=1). All presented with local pain and limping or inability to walk (except one case with hand involvement). Four patients had fever and inflammatory signs, namely erythema and edema, were reported by four. At admission, nine had elevated inflammatory markers and six out of eight had normal radiographs. Magnetic resonance imaging confirmed the diagnosis in seven. Blood cultures were positive for Staphylococcus aureus (n=3) and Streptococcus pyogenes (n=1). Salmonella enteritidis was isolated from pus (n=1) and there was one presumed Kingella kingae AO defined as a positive polymerase chain reaction test from an oropharyngeal swab. The average duration of parenteral and oral antibiotherapy was 14.7 days 3.9 weeks, respectively. The antibiotic of choice was flucloxacillin. Two patients developed local complications.DISCUSSION: An unspecific and subacute clinical and radiological presentation together with low positive blood culture rates difficults timely diagnosis and management. An early empirical parenteral antibiotherapy is mandatory, followed by an oral regimen for at least four weeks.

Acute Primary Epiphyseal Osteomyelitis of Proximal Tibia - A Case Report and Review of the Literature.

Introduction:Acute pyogenic epiphyseal osteomyelitis is a rare condition, mostly affecting children. This case report discusses the importance of clinical suspicion and the role of adjuncts in the diagnosis of these cases.Case Presentation:A 12-year-old female presented with pain in the right knee for 1 week and difficulty in walking for 4 days. Diagnosis was made with the help of magnetic resonance imaging MRI and guided biopsy. Pseudomonas aeruginosa was isolated from culture. She was treated with intravenous antibiotics with a good response.Discussion:Despite being a rarely reported entity, primary epiphyseal osteomyelitis should be kept as one of the differentials of the painful swollen knee in a child. Early diagnosis with the help of proper radiological investigations is the key to prevent the sequelae of this disease.

RADIOLOGICAL SPECTRUM OF OSTEOMYELITIS

Osteomyelitis remains a vexing illness and the outcome is often unsatisfactory despite major advances in surgery and antimicrobial therapy. Clinical experience is the guidebook for management as there is a paucity of controlled clinical trials and a lack of long term follow up in most published reports. The term "Osteomyelitis" taken implies inammation of the bone and its marrow regardless of whether it is due to pyogenic organisms, tuberculosis, Syphilis, a specic virus or the presence of a foreign body such as shrapnel. Osteomyelitis affects the metaphysic of long bones commonly out of which the bone ends in small children are most susceptible sites. Osteomyelitis in drug addicts may occur in unusual locations, such as clavicle and sternum. Axial involvement appears to be more prevalent than long bone involvement. Post-traumatic and postoperative osteomyelitis develops after treatment for compound fractures, prosthetic replacement and pin-track xation. Radiologically the acute and subacute osteomyelitis pose a diagnostic problem due to very little or absent radiological evidence. Chronic osteomyelitis is more a disease of chronic ischemia than of chronic sepsis

OPTIMIZATION OF SURGICAL INTERVENTION METHODS IN THE TREATMENT OF ODONTOGENIC CYSTS OF THE UPPER JAW

Abstract: The therapy of odontogenic cysts of the upper and lower jaws, both conservative and operative, is of a complex nature – the frequency of this disease, according to the data, does not decrease. A number of researchers believe that the risk of inflammatory complications in odontogenic cysts is very high. The result of the injection of an odontogenic cyst of the upper jaw can be the occurrence of acute osteomyelitis with the development of a fistula and the outflow of purulent discharge into the maxillary sinus, which can later lead to the development of chronic odontogenic sinusitis. Studies of pus and granulations and analysis of the results obtained in most cases indicate a mixed microflora (staphylococcus, streptococcus, proteus, etc.). Also, when analyzing the literature, it was noted that the surgical treatment of odontogenic cysts localized on the upper jaw, as well as the use of osteoplastic materials for filling bone defects is very ambiguous and contradictory. The authors justify this fact by the fact that there is a high risk of relapses, in particular, after cystectomy, the probability of relapse is at least 17.8%. The usual scenario for conducting such nosologies is radical excision of odontogenic cysts of the jaws, after which a long time is needed to restore the bone defect, as well as adequate subsequent prosthetics. Based on these data, modern authors develop low-traumatic, sparing methods of surgical treatment of odontogenic cysts, especially of the upper jaw, including using endoscopic techniques. Based on the above, an urgent task for dental surgeons is to optimize the methods of surgical treatment of odontogenic cysts of the upper jaw, in particular with a decrease in the volume of the operating field.

Bone complications in Gaucher disease

Purpose: Gaucher disease (GD; OMIM # 230800) is an autosomal recessively inherited lysosomal storage disease. GD is caused by a deficiency of the lysosomal enzyme, glucocerebrosidase (GBA, also called acid ß-glucosidase or GCase), which hydrolyzes glucosylceramide (GlcCer) into ceramide and glucose. As a consequence of mutations in the GBA1 gene located on chromosome 1 (1q21) there is an accumulation of GCase substrate, GlcCer, in macrophages. Bone tissue represents a large systemic compartment of the human body, with an active metabolism that controls mineral deposition and removal, and where several factors may play a role. For these reasons, several non-skeletal diseases may influence bone metabolism. Methods: The present review describes bone skeletal manifestations in the GD and the role of several factors. This manuscript is the result of a review of the literature that focused on the bone manifestations of GD. In particular, relevant studies were identified through a PubMed search strategy. Step 1 consisted of a systematic literature search using the terms: Bone Metabolic Rare Diseases, Hematological Rare Diseases, Gaucher Disease; step 2 involved adding the terms “osteoporosis” or “bone mass”, or “bone turnover” or “bone fragility” or “bone deformity”, or “bone biomarkers”. Results: The skeletal manifestations of GD include a variety of bone pathologies due to various factors. These pathologies include bone infarcts, avascular bone necrosis, cortical thinning, lytic bone lesions, osteosclerosis and fractures due to osteopenia or osteoporosis, and rarely acute osteomyelitis. Conclusions: Bone loss in patients with GD should be managed, whenever possible, at or in close liaison with a center that specializes in the diagnosis, management and therapy of metabolic bone diseases. A multidisciplinary approach is important to better understand the complexity and pathogenesis of bone involvement in GD. In this way it will be possible to refine and standardize the diagnostic and therapeutic approaches to bone disease in GD.

Computed and magnetic resonance imaging for osteomyelitis in children

Introduction. The frequency of osteomyelitis in pediatric population is approximately 1:5000, and the mortality rate is from 0.2% to 17.0%. In children, acute bone infection is most often of hematogenous origin. Transition from the classical radiography and radionuclide examination to computed tomography (CT) and magnetic resonance imaging (MRI) has been completed.Purpose. To demonstrate potentials of CT and MRI in the diagnostics of osteomyelitis in children.Material and methods. 238 children with osteomyelitis, aged 1-17 years (average 9.1 ± 4.9 years), were examined for the last ten years. There were 126 boys (53%) and 112 girls (47%). Depending on the disease nosology, patients were divided as follows: hematogenous osteomyelitis (n = 112 children, 47%), BCG-osteomyelitis (n = 20, 8.4%), post-traumatic osteomyelitis (n = 67, 28.2%). 138 children (58%) were treated surgically. CT scanning was performed in 174 patients using Brilliance 16 scanners. MRI was performed using Philips AchievadStream 3.0 T scanner to obtain multi-planar STIR, T1-, T2- and PD weighted images (SE and GE). In addition, new MRI methods were used: diffusion-weighted images (DWI), Dixon, dynamic MRI with contrast enhancement (DCE).Results. CT examination, which was performed in 174 patients at the same terms as radiography, confirmed density decrease ( though not large). Periosteal changes were better visualized at CT examination in 107 out of 174 patients (61.5%) including those who had changes at the classical radiography. MRI was performed in 51 patients ( including those with intravenous contrast enchancement) on Day 2-3 since the disease onset. This examination was effective in all cases (sensitivity 100%). T2WI and STIR with fat suppression (FS) clearly revealed edema of the bone marrow and surrounding muscles as well as small changes.Conclusion. MRI is the most informative diagnostic technique in acute osteomyelitis at its early period because main signs of the initial stage of this disease - edema of bone marrow, periosteum and soft tissues - are detected during the first days. In addition, MRI reveals details of bone and soft tissues damages, including abscess and sequester formation, especially in spinal and pelvic lesions. MRI sensitivity in osteomyelitis reaches up to 100%. Sequences with the fat suppression (FS) can better detect bone marrow edema and inflammation than radiography. MRI is a preferable technique in diagnostics of infectious lesions of the spine, pelvis, and limbs.

A Comprehensive Review of the Pathogenesis, Diagnosis, and Management of Diabetic Foot Infections.

To review an approach to diabetic foot infections (DFIs), including acute osteomyelitis, while also discussing current practices and the challenges in diagnosis and management. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant will1. Identify the risk factors for developing DFIs.2. Outline diagnostic techniques for assessing DFIs.3. Select the assessment techniques that support a diagnosis of osteomyelitis.4. Choose the appropriate pharmacologic and nonpharmacologic treatment options for patients who have DFIs. Diabetic foot ulcers result from a combination of peripheral neuropathy, vascular compromise, and repetitive trauma. Approximately 50% of individuals with diabetic foot ulcers will develop a diabetic foot infection (DFI), and 20% of individuals with a DFI will develop osteomyelitis. Herein, the authors review an approach to DFIs including acute osteomyelitis and discuss current practices and challenges in diagnosis and management.The diagnosis of a skin and soft tissue DFI is based on clinical criteria. A bone biopsy is considered the criterion standard for diagnosis of osteomyelitis; however, biopsy is not always feasible or available. Consequently, diagnosis can be made using a combination of clinical, biochemical, and radiographic findings. X-ray is the recommended imaging modality for initial evaluation; however, because of its lower relative sensitivity, advanced imaging may be used when clinical suspicion remains after negative initial testing.The microbiology of skin and soft tissue DFIs and osteomyelitis is similar. Staphylococcus aureus and other Gram-positive cocci are the most common pathogens identified. Deep cultures are preferred in both DFI and osteomyelitis to identify the etiologic pathogens implicated for targeted antimicrobial therapy. Management also requires a multidisciplinary approach. Surgical debridement in those with deep or severe infections is necessary, and surgical resection of infected bone is curative in cases of osteomyelitis. Finally, appropriate wound care is critical, and management of predisposing factors, such as peripheral neuropathy, peripheral arterial disease, tinea, and edema, aids in recovery and prevention.

Acute hematogenous osteomyelitis with total sequestration of the left anonymous bone in a child

As you know, in children, the treatment of osteomyelitis should be more conservative than in adults. However, the use of antibiotics, even in the early stages and in large doses, does not give favorable results in all cases, and surgical intervention becomes inevitable, which was observed in the given case.

Magnetic resonance imaging texture analysis in the quantitative evaluation of acute osteomyelitis of the mandibular bone.

Accurate assessment of radiological images can help in early diagnosis and therapy of suppurative osteomyelitis (OM). The purpose of this study was to apply texture analysis to MRI as a means of quantitatively evaluating acute OM of the mandible. We analyzed the data from 38 patients who complained of pain and underwent MRI between April 2017 and March 2019. From the MRIs of these patients, with (n = 19) and without OM (n = 19), 279 radiomics features were extracted using short tau inversion recovery, data of the regions of interest and analyzed with MaZda v. 3.3. 10 features, including one histogram feature (90th percentile), eight gray-level co-occurrence matrix features (Sum Averg), and one gray-level run-length matrix feature (Horzl_RLNonUni), were selected using Fisher coefficient and compared between the acute OM and non-OM groups. The two groups were compared using Mann-Whitney U test with p value set at 0.05. All 10 radiomics features showed significant differences between the acute OM and non-OM groups (p < 0.05). MRI texture analysis has potential application in radiomics diagnosis of acute OM of the mandible.

Clinical Outcome and Antibiotic Dosing Differences by Weight in Children With Acute Osteomyelitis

To evaluate for weight-based differences in clinical outcomes and antibiotic dosing variability for children hospitalized with acute hematogenous osteomyelitis (AHO). We performed a retrospective cohort study of children aged 2 to 17 years and hospitalized with a primary AHO International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision diagnosis code between 2010 and 2017 using the Cerner Health Facts database. Weight categories (healthy, overweight, obesity) were determined by using Centers for Disease Control and Prevention age- and sex-specific BMI percentiles. Rates of procedures, complications, and length of stay (LOS) were compared between groups. Dosing variability between groups was assessed by comparing the initial milligrams per kilogram per day of prescribed antibiotics. We identified 755 children with AHO for inclusion. Children with overweight and obesity were more likely to undergo surgical procedures (19% and 17%, respectively) compared with children with a healthy weight (10%; P = .009). They also had a longer LOS (5.7 and 5.8 days) than children with a healthy weight (4.9 days; P = .03). There were no differences in complication rates between weight categories. Mean weight-adjusted daily dose for the most frequently prescribed antibiotics was different by weight category, with children in higher weight categories more likely to receive lower weight-based doses. Children with overweight and obesity hospitalized for AHO were more likely to undergo procedures, have longer LOS, and receive lower weight-based antibiotic dosing compared with children with a healthy weight. Our findings suggest that weight should be carefully considered when treating children with AHO.

Approach to Suspected Physeal Fractures in the Emergency Department.

Growth plate (physeal) fractures are defined as a disruption in the cartilaginous physis of bone with or without the involvement of epiphysis or metaphysis. These represent around 15-18% of all pediatric fractures. It is important to diagnose physeal injury as early as possible, as misdiagnosis or delay in diagnosis may result in long term complications. Physeal injuries may not be initially obvious in children who present with periarticular trauma, and a high index of suspicion is important for diagnosis. Differential diagnosis for a Salter-Harris fracture includes a ligamentous sprain, acute osteomyelitis, or an extraphyseal fracture such as a Torus fracture. Salter-Harris I & Salter-Harris II growth plate fractures commonly are commonly managed by closed manipulation, reduction & immobilization. These are relatively stable injuries and can be retained by adequate plaster. Salter-Harris III & Salter-Harris IV fractures require anatomical reduction with the maintenance of congruity of joint. Physeal fractures can have many complications such as malunion, bar formation, acceleration of growth of physis, posttraumatic arthritis, ligament laxity and shortening of the bone. The key to well-healing fractures is successful anatomic reduction and patients must have regular follow-up for these injuries.

BACTERIAL MYOCARDITIS IN SICKLE CELL PATIENT WITH ACUTE CHEST SYNDROME

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sickle cell anemia is an autosomal recessive disorder leading to chronic hemolytic anemia secondary to abnormal hemoglobin. Sickle cell anemia has numerous clinical consequences such as acute pain crisis, acute chest syndrome, osteomyelitis, and renal failure. The most common cause of death for sickle cell patients is infection. A rare cause of death for sickle cell patients is infection secondary to viral myocarditis; and even rarer is bacterial myocarditis. In this case, our sickle cell patient passed away from a staphylococcal bacterial myocarditis. CASE PRESENTATION: A 44-year-old female with a significant past medical history of Sickle Cell Disease (Hemoglobin SS) presented to the emergency department with complaints of shortness of breath, 5 days of fever with abdominal pain and dysuria. Initial pertinent investigations showed a hemoglobin of 5.3, WBC 23.5, and mild hypokalemia with an acute kidney injury with elevated BUN/Creatinine (71/2.31). The urine analysis was positive, although the culture was negative. Blood cultures were drawn. Ceftriaxone and IV fluids were started. A CT abdomen and chest was obtained and showed mixed alveolar and interstitial opacities in bilateral lower lobes consistent with acute chest syndrome, hepatomegaly, and an enlarged heart. She was transferred to a tertiary center due to acute sickle cell pain crisis complicated by AKI, and acute chest syndrome. Patient was given a PCA pump with hydromorphone. Hematology recommended starting hydroxyurea and transfusing 2 units packed red blood cells. Troponin levels became elevated. Echocardiogram showed no wall motion abnormalities and a normal ejection fraction (50-55%). Patient continued to clinically deteriorate, so an exchange transfusion was started. During the exchange transfusion the patient coded and passed away. An autopsy was performed and showed interstitial neutrophilic infiltrates within the myocardium with micro abscesses with gram positive cocci identified. Blood cultures were positive for Staphylococcus aureus. The cause of death was identified as staphylococcal bacterial myocarditis. DISCUSSION: Sickle cell patients are susceptible to serious adverse outcomes from infections; notably infections are the leading cause of death in sickle cell patients. Death is often sudden and unexpected. Our patient was an example of an extremely rare cause of staphylococcal bacterial myocarditis with a concomitant acute chest syndrome that may have contributed to masking the underlying myocarditis and thus ultimately leading to death. CONCLUSIONS: Bacterial myocarditis is a very rare but potential cause of death in patients with sickle cell disease and the symptoms could be concealed from the clinician due to and overlapping acute chest syndrome. REFERENCE #1: Manci EA, Culberson DE, Yang YM, et al; Investigators of the Cooperative Study of Sickle Cell Disease. Causes of death in sickle cell disease: an autopsy study. Br J Haematol. 2003 Oct;123(2):359-65. REFERENCE #2: Cooper LT Jr. Myocarditis. N Engl J Med. 2009 Apr 9;360(15):1526-38. REFERENCE #3: McGee M, Shiel E, Brienesse S, et al; Staphylococcus aureus Myocarditis with Associated Left Ventricular Apical Thrombus. Case Rep Cardiol. 2018 May 23;2018:7017286. DISCLOSURES: No relevant relationships by Chad DeMott, source=Web Response No relevant relationships by Badri Giri, source=Web Response No relevant relationships by Elspeth Springsted, source=Web Response

A CASE OF NEONATAL OSTEOMYELITIS

Acute hematogenous osteomyelitis of neonatal origin is very rare in clinical studies. Early diagnosis and treatment are important to decrease the morbidity. The aim is to provide a reference case for medical practitioners for early diagnosis and treatment of cases like this with symptoms, signs, blood investigations, radiological studies and blood culture outcomes. There have not been any adverse sequelae after effective antibiotic therapy. Timely diagnosis and management of neonatal osteomyelitis are of significant importance.

Treatment of acute osteomyelitis (Zentr. f. Ch., 1926, № 18)

Treatment of acute osteomyelitis was the programmatic theme of the XV Congress of Surgeons in Copenhagen on June 25-27, 1925 (Zentr. F. Ch., 1926, no. 18). Speakers on this issue, Johanson nSchilling, generally agreed that radical removal of the affected bone marrow is the treatment of choice for acute osteomyelitis.

A Review of Consecutive Cases to Identify the Rate of Underlying Osteomyelitis in Patients Undergoing Surgical Treatment of Gangrene of the Forefoot and Impact of Acute Infection on Outcome Following Amputation

Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.

Culture-negative chronic hematogenous osteomyelitis in a two months old girl: a case report

BackgroundPrevious articles have focused on the diagnosis and treatment of acute hematogenous osteomyelitis. Here, we present a case of chronic hematogenous osteomyelitis in a 2-month-old girl. The diagnostic procedure was unusual and difficult due to negative culture results.Case presentationA girl aged 2 months and 23 days had fever and swelling in her right lower leg for 7 days. On the basis of her medical history, physical, and histological examination results; and radiologic and magnetic resonance imaging findings, a diagnosis of chronic osteomyelitis was made. The patient underwent surgical treatment and was discharged successfully. The patient showed good recovery and no sequelae at the 12-month follow-up.ConclusionHematogenous osteomyelitis in babyhood is different from that at any other age. Hematogenous osteomyelitis-related bone destruction in babyhood is more serious and occurs faster. The transition from acute hematogenous osteomyelitis to chronic hematogenous osteomyelitis takes only 7 days. To the best of our knowledge, this chronic hematogenous osteomyelitis patient is the youngest ever reported.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics.

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Intravenous fosfomycin for the treatment of patients with bone and joint infections: a review

ABSTRACT Introduction Fosfomycin is a wide spectrum bactericidal antibiotic with a unique mode of action, low toxicity, and good penetration in tissues with deep-seated infections, including bone and joint infections. Areas covered Data were extracted from 19 published articles. Three hundred and sixty-five patients, with broad age range, received intravenous fosfomycin for the treatment of bone and joint infections (including arthritis, acute and chronic osteomyelitis, discitis, periprosthetic joint infection). Fosfomycin was given as part of a combination antimicrobial therapy in the majority of patients (93.7%). The dosage of fosfomycin ranged from 4 g/day (in one case) to 24 g/day. The dosage of fosfomycin, in some cases, mostly pediatric, was calculated based on body weight, ranging from 50 mg/kg/day to 250 mg/kg/day. The duration of fosfomycin treatment ranged from a couple of days up to 3 months. The most common isolated pathogen was Staphylococcus aureus (38.9%). Three hundred patients (82.2%) were successfully treated. Fosfomycin was well tolerated, as few patients developed mild adverse events, mostly gastrointestinal discomfort, hypernatremia, skin rash, and neutropenia. Expert opinion The available data suggests that intravenous fosfomycin may be beneficial for the treatment of patients with bone and joint infections, especially when used as part of a combination antibiotic regimen.

Epidemiology and Management of Acute Hematogenous Osteomyelitis, Neonatal Osteomyelitis and Spondylodiscitis in a Third Level Paediatric Center.

Acute hematogenous osteomyelitis (AHOM) is a rare pathology in pediatric population. The aim of this study is to analyse the epidemiological data and the management, compared to European Society for Paediatric Infectious Disease (ESPID, European Society for Pediatric Infectious Diseases) guidelines 2017 of 216 children with AHOM, divided in three cohorts (neonatal-onset osteomyelitis, those with vertebral involvement and other types of osteomyelitis). We conducted a retrospective single center study, evaluating data from all the children (aged 0–18 years) consecutively admitted to the Meyer Children’s Hospital, during a period of ten years (1 January 2010–31 December 2019). Isolation of pathogen was possible in 65 patients and S. aureus was the most frequently involved (43/65 children). Magnetic Resonance Imaging (MRI, magnetic resonance imaging) was performed in 201/216 cases and was compatible with osteomyelitis in 185/201 of these children (92.03%). In the neonatal-onset osteomyelitis group the percentage of diagnostic ultrasound for osteomyelitis was 36.36% significantly higher than the other groups. The median duration of total antibiotic therapy was 37.5 days. In total, 186/199 children recovered without complications. The present study delineates three heterogeneous cohorts of patients. S. aureus is confirmed as the first pathogen for isolation in all three groups analysed. MRI represent a gold standard for diagnosis. Longer duration of antibiotics treatment was performed in neonatal and spondylodiscitis group, compared to the other types of osteomyelitis.